DIVISIONAL BULLETIN September 2013 New heath service structures Introduction In November 2012 the Minister for Heath aunched Future Heath: A Strategic Framework for Reform of the Heath Service 2012-2015. The docu ment contains 48 actions and time ines for impementing changes. IMPACT-comm - issioned research on a number of aspects of the proposed heath reforms was pubished in November 2012. The union aso sought to engage with the Minister and his department on the findings of our research, which highighted a number of areas of concern in reation to Future Heath. However the Minister has consistenty decined to meet with the union on this matter. The union aunched a Heath Score Card at its May 2013 Heath & Wefare conference. The document demon strated that the Minister and his department had faied to meet their own deadines in 16 out of 20 actions schedued to be in pace by Apri 2013. A further update on this is panned for the autumn. This buetin gives a brief overview of some of the key changes now taking pace under the heath reform process and outines IMPACT s experience of them so far. Hospita custers and trusts A new hospita groups system is meant to drive the transition to a singe-tier heath service, supported by universa heath insurance (UHI). Under the new mode there wi be six arge hospita groups nationwide. Each group wi incude a range of hospitas, capabe of providing genera medica, acute care, day surgery, and eective inpatient surgery. Each group wi have at east one major university teaching hospita, a nationa cancer contro programme (NCCP) centre, and a maternity service. A chief executive officer (CEO) wi be appointed in each group. The CEO wi have budgetary and overa staff responsibiity for both the HSE and vountary hospitas in their group. The six proposed hospita groups are: Dubin North East: Beaumont Hospita; Our Lady of Lourdes Hospita, Drogheda; Connoy Hospita; Cavan Genera Hospita; Louth County Hospita; Monaghan Hospita. Dubin Midands: St James s Hospita; The Adeaide and Meath Hospita Dubin, incuding The Nationa Chidren s Hospita; Midands Regiona Hospita, Tuamore; Naas Genera Hospita; Midands Regiona Hospita at Portaoise; the Coombe Women and Infant University Hospita. Dubin East: Mater Misericordiae University Hospita; St Vincent s University Hospita; Midand Regiona Hospita at Muingar; St Luke s Genera Hospita, Kikenny; Wexford Genera Hospita; St Michae s Hospita, Dun Laoghaire; Cappagh Nationa Orthopaedic Hospita; Roya Victoria Eye and Ear Hospita. South/South West: Cork University Hospita/Cork Uni - versity Maternity Hospita; Waterford Regiona Hospita; Kerry Genera Hospita; Mercy University Hospita; South Tipperary Genera Hospita; South Infirmary Victoria University Hospita; Bantry Genera Hospita; Maow Genera Hospita, Kicreene Orthopaedic Hospita. West/North West: University Hospita Gaway and Merin Park University Hospita; Sigo Regiona Hospita; Letterkenny Regiona Hospita; Mayo Genera Hospita; Portiuncua Hospita; Roscommon County Hospita. Midwest: Mid-Western Regiona Hospita, Dooradoye, Limerick; Ennis Genera Hospita; Nenagh Genera Hospita; St John s Hospita; Mid-Western Regiona Maternity Hospita; Mid-Western Regiona Orthopaedic Hospita. 1
The Report of the Nationa Acute Medicine Programme 2010 said that every hospita in the country woud fa into one of four categories: Mode 1 hospitas wi be community/district hospitas, with sub-acute in-patient beds. Mode 2 hospitas wi provide in-patient and out-patient care for differentiated, ow-risk medica patients who are not ikey to require fu resuscitation. Mode 3 hospitas wi be responsibe for un - differentiated acute medica and surgica patients. Mode 4 hospitas wi admit undifferentiated acute medica patients incuding tertiary referred patients. Each new hospita group wi have at east one of each type of hospita. to have diagnostic functions transferred to the hospita from other parts of the new hospita group. So far, the experience in the Midwest hospita group has been better, with no significant outsourcing. There have been no immediate probems over recruitment through outsourcing, athough there are concerns that the union wi have to resist outsourcing and privatisation once the hospita group achieves trust status. The biggest probem in the Midwest group is the inabiity to repace cerica and administrative staff due to ack of funding. IMPACT beieves that the transition from hospita groups to hospita trusts wi not be a success uness adequate funding is forthcoming. Athough the Midwest has improved services (exampes incude the opening of a new diaysis unit and a fa in consutant waiting times) further improvements wi not be achievabe without additiona funding and recruitment to key vacant posts. Experience to date Two groups, the Midwest and the West/Northwest, have aready been estabished. Two main issues have emerged in the West/Northwest group; a ack of consutation about the new structures, and attempts to outsource work currenty carried out by existing directy-empoyed staff. The new management structure of the new hospita groups sees the introduction of a CEO, a chief operations officer (COO) and a chief finance officer (CFO). Initiay, the HSE intended to outsource these positions, aong with the management of the hospita. This woud have set a very dangerous precedent across the pubic service. IMPACT successfuy fought this proposa and succeeded in having the posts advertised by pubic competition. The fact that IMPACT members successfuy competed for two of these posts demonstrates that existing pubic sector managers can compete successfuy against externa appicants for top jobs. However, the HSE continues to try to outsource job openings in areas such as IT, safety and risk, and catering. IMPACT has repeatedy expressed its dissatisfaction with the ack of consutation over outsourcing. The union has tod management that it s strongy against this method of fiing positions and is insisting on direct provision in recruitment and service deivery. This is a view shared by other unions and we have estabished a West/Northwest group of unions to hep dea with this and other probems arising from the estabishment of the hospita groups. The union group has estabished reguar meetings with management, where both sides can tabe issues they want addressed. This forum has agreed terms of reference and joint chairs and has been very effective. There have aso been incidents of redepoyment within the group, especiay in the area of corporate services. IMPACT success fuy intervened to avoid staff being redepoyed ong distances from Roscommon hospita by negotiating Management s proposas on directorates As part of Future Heath, Minister Reiy signed into effect a number of changes to HSE governance arrangements, which took effect on 25th Juy. In short, the HSE was dissoved and repaced with a new directorate. A new interim structure is meant to estabish a more direct ine of accountabiity between the HSE and the Minister. HSE director genera designate Tony O Brien was appointed as director genera and chairman of the directorate. A number of nationa directors have aso been appointed. They incude Laverne McGuinness (chief operating officer and deputy director), Tom Byrne (chief financia officer), John Hennessy (director primary care), Ian Carter (director acute hospitas), Pat Heay (director socia care), Stephen Muvany (director menta heath) and Stephanie O Keeffe (director heath and webeing). Four regiona directors for performance and integration (RDPIs) were aso introduced to impement regiona improvements in integration and performance in the new service sectors. They report directy to the nationa directors. The directorate is accountabe to the Minister for the performance of the HSE s functions as we as its own. As chairperson, the director genera wi account to the Minister on behaf of the directorate in regard to how the HSE s functions are performed. In each case, the directorate management team wi have a cear budget and a mandate to deiver sustained performance improve - ment. The directorate management teams invoved in performance contracting and financing of services wi be subsumed into a new commissioning body caed the Heathcare Commissioning Agency in 2014. They wi be accountabe for continuing to drive performance improve - ment. 2
Experience to date It has been very difficut to get information about how the directorates wi work in practice. Foowing a meeting with Tony O Brien, it emerged that most IMPACT members wi experience itte or no short-term change in their day-today reporting reationships. However it is cear that the current mode of 17 integrated service areas wi be revamped in future. IMPACT is seeking an input into ongoing work on future reporting reationships. In the meantime, the HSE has provided a ist, which identifies what functions are going into the different directorates (see Appendix 1 pages 7 and 8). Aong with these directorates there wi aso be finance, HR and shared services. The Chid and Famiy Agency The Chid and Famiy Agency Bi 2013 proposes the estabishment of a Chid and Famiy Support Agency. The existing Famiy Support Agency, Nationa Educationa Wefare Board and HSE-operated chid protection and wefare services wi be dissoved. Their chid and famiy functions wi transfer to the new agency, which wi be overseen by a singe dedicated government department. The new agency wi have a strong roe in prevention, eary intervention, ongoing intervention to support famiies and communities, and accessing speciaised services. Like the hospita groups, the agency is meant to operate within a strong framework of pubic accountabiity and wi create direct ines of accountabiity from area manager to CEO. Experience to date IMPACT members in socia care, socia work, and famiy support professions aong with associated cerica and administrative staff wi a be encompassed by the move to the new agency. IMPACT succeeded in securing the protection of workers conditions of empoyment in section 83 of the Bi, which preserves the terms and conditions of staff. This incudes remuneration and tenure, and aso protects previous service. Negotiations on the industria reations aspects of the estabishment of the agency are currenty underway with third party assistance. IMPACT has highighted the issue of inadequate numbers across a grades for the new agency and has caed for additiona recruitment in every area. Recenty, 400 administrative staff took part in a survey about joining the agency and the resuts wi be pubished soon. Shared services A meeting took pace between HSE and IMPACT on 25th June 2013, where it was announced that the shared services directorate had been re-estabished and woud incude procurement, ICT, finance, estates, ega, SAP/HR and PPARS. Nationa director Liam Woods proposed a forum invoving IMPACT to discuss the consequences of the Haddington Road agreement in reation to shared services. It was aso reveaed that consutants Ernst and Young wi assess and review the directorate and the deveopment of the structure for shared services. It is expected that the HSE wi soon put forward proposas providing a broad picture for the future. The HSE intends to expand shared services across the whoe of the heath sector. Sma hospitas The Government s heath reform pans wi see hospitas divided into six reativey arge hospita groups in a bid to rebaance, rationaise and reorganise services. Each group wi incude a range of hospitas capabe of providing genera medica acute care, day surgery and eective inpatient surgery. The introduction of these hospita groups and the deveop - ment of sma hospitas are interreated. Executive teams estabished in each of the six hospita groups are to drive the deveopment of smaer hospitas. According to the Government, sma hospitas wi continue to pay a pivota roe in the deivery of services. The HSE report Securing the Future of Smaer Hospitas: A Frame - work for Deveopment paces the future growth in Irish heathcare firmy in oca (sma) hospitas, which wi provide ambuatory care, diagnostics and rehabiitation, and have cose inks to primary heath care services to oca popuations. So the Government has committed to the further deveopment of the smaer hospitas. The HSE says sma hospitas have immense capacity for fexibiity and change and have said that no acute hospitas wi cose. Its framework for deveoping sma hospitas describes how it intends to maintain the security and deveopment of smaer hospitas. It focuses on the roe of nine smaer hospitas: Dubin North East Our Lady s Hospita Navan Louth County Hospita Dundak Dubin Mid Leinster St. Comcie s Loughinstown South Maow Bantry West Ennis Nenagh St. John s Limerick Roscommon County Hospita 3
The HSE framework does not underestimate the contribution smaer hospitas make to the Irish heath system and says they can hep deiver faster access for patients by increasing the voume of eective services they provide in seected speciaties. It says arger hospitas must recognise the services smaer hospitas offer and concentrate on the more compex care that ony arger hospitas can provide. The HSE has said it can and wi expand the services deivered in smaer hospitas, especiay in services such as day surgery, ambuatory care, medica services and diagnostics. Much of this type of work is sti carried out argey in the bigger hospitas, which makes itte sense as they can safey be carried out in smaer settings. The HSE framework aso says smaer hospitas provide a unique and essentia opportunity for the undergraduate and postgraduate training of heathcare professionas. In order to ensure these benefits are acknowedged, education and training shoud be organised across the new hospita groups. Furthermore, staff working within smaer hospitas need to be fu participants in network-based continuous professiona deveopment programmes. The new payment system wi appy to medica assessment units, acute medica assessment units, acute medica units, cinica decision units, day wards or in patient wards which are, or coud be, deivered on a side-room or outpatient basis. Certain services incuding emergency departments, teaching, and researching costs wi be excuded from the money foows the patient system. Long-term residentia care and outreach services wi aso be excuded from the payment system. A new statutory body, caed the Heathcare Commissioning Agency wi draw up annua performance contracts with each of the hospita groups using the nationa diagnosis reated groups (DRG) priceist, as we as the goba hospita budget and service targets handed down by the minister. The agency wi aso set quaity targets underpinned by financia sanctions, encouraging hospitas to provide the best possibe care to patients. The minister wi aso provide funding for additiona targeted activity. But ony hospitas that meet their activity targets in the previous quarter wi be eigibe to bid for this additiona funding. So, hospitas with waiting ists coud find that patients are treated esewhere, with the money foowing the patient. IMPACT view Staff and patients in smaer hospitas are understandaby fearfu of being subsumed by arger ones in the proposed hospita group configuration. Despite Government ass - urances, the major concern is that their assets and services wi be stripped and moved to arger hospitas, and that they may ose their unique hospita cuture. On the face of it, the introduction of the new system does not impy any change in staff pay and conditions. However, the new roes of sma hospitas within arger custers coud ead to fewer functions taking pace outside of standard 9-5 hours, with impications for premium and overtime payments. The union is aso concerned that there may be a bias towards arger hospitas when functions are aocated, and that this coud pace smaer hospitas under further funding pressure. IMPACT has raised these concerns with the HSE and wi be monitoring the situation during and after the impementation of the new system. The union has demanded oca-eve consutation on any changes and is committed to protect staff terms and conditions. Money foows the patient The new payment system caed money foows the patient' is meant to create a fairer system where hospitas are paid for the care they actuay deiver, rather than receiving a pre-determined standard grant. The HSE says providers wi be funded for the quantity and quaity of the services they provide and the outcomes they achieve. IMPACT view of money foows the patient The money foows the patient system is meant to ensure that funding for hospitas is directy inked to the number and type of procedures they deiver to patients. The HSE pans to put a standard vaue on medica procedures performed in hospitas a hip repacement, for exampe. This vaue wi take account of theatre time, nursing and other care, anesthetic provision, ight and heat, and so on. Generay speaking, hospitas wi then be funded ony for the procedures that they actuay perform. It remains to be seen whether, and how, this wi operate in practice; there are no internationa exampes of how the money foows the patient system envisaged by the HSE woud work in a pubic hospita. However, IMPACT beieves there are a number of potentia faws in the approach adopted by the HSE: Whie it is possibe to see how a system ike this woud work for straightforward procedures, it wi be much more difficut to pace a standard price on treatment for patients who present with compex or mutipe conditions. The system wi not take account of compications that arise, even from simpe procedures. If compications resut in hospitas spending more than the price paced on a procedure they wi have to chase the HSE for additiona funding after the event. It has been suggested that the HSE may under - estimate the cost of procedures in order to promote competition. If it does, it is virtuay inevitabe that funding crises wi emerge. 4
A hospitas wi get the same sum for a given pro - cedure regardess of the age and condition of its faciities (or indeed staff vacancies or shortages). This may mean significant underestimation of the rea costs of providing services in some hospitas or resut in a bias towards better-equipped hospitas, eaving patients with onger distances to trave for treatment. Or both. It is not yet cear how the necessary data about procedures wi be coected. However, it s cear that a significant additiona administrative burden wi be paced on aready short-staffed hospitas, which do not currenty have systems in pace to track procedures and costs to the eve of detai required to make money foows the patient work. It is by no means certain that a hospitas wi be abe to put the required systems in pace. Impact of money foows the patient on staff On the face of it, the introduction of the new system does not impy any change in staff pay and conditions. However, there wi be additiona work and some staff wi ikey be caed upon to do new tasks reated to the coection and coation of patient information and reated matters. The union aso has some concerns that, over time, the system coud hit funding for some hospitas, which coud ead to pressure on budgets and working conditions. The union has raised these concerns with the HSE and wi be monitoring the situation during and after the impemen - tation of the new system. More information The future of heathcare in Ireand, by Dr Jane Piinger (IMPACT, November 2012). Red card for heath reforms, (IMPACT Heath & Wefare Division, May 2013). IMPACT buetin on new heath service structures (September 2013). These pubications are avaiabe from www.impact.ie, which aso carries updates on union and heath service issues. 5
Appendix 1 HSE: Transfer of corporate functions 24th Juy 2013 Acute Services Acute Services Nationa Office Integrated Services Directorate Acute Services Division Ian Carter Gaway/Roscommon and Integrated Services Directorate Acute Services Division Ian Carter Mid Western Hospita Groups Treatment Abroad Scheme Integrated Services Directorate Acute Services Division Ian Carter EU Schemes Integrated Services Directorate Acute Services Division Ian Carter EU Cross Border Directive Integrated Services Directorate Acute Services Division Ian Carter impementation Menta Heath Services Menta Heath Services Integrated Services Directorate Menta Heath Division Stephen Muvany Nationa Office Nationa Office Suicide Prevention 1 Integrated Services Directorate Menta Heath Division Stephen Muvany Primary Care, Socia Incusion PCRS Integrated Services Directorate Primary Care Division John Hennessy Primary Care Nationa Office Integrated Services Directorate Primary Care Division John Hennessy Socia Incusion Nationa Office Integrated Services Directorate Primary Care Division John Hennessy Drug Treatment Centre Integrated Services Directorate Primary Care Division John Hennessy GP Out of Hours Integrated Services Directorate Primary Care Division John Hennessy Civi Registration (Nationa Lead) Integrated Services Directorate Primary Care Division John Hennessy Nationa Contracts Office Integrated Services Directorate Primary Care Division John Hennessy Ora Heath Nationa Office Integrated Services Directorate Primary Care Division John Hennessy 1 The Nationa Office for Suicide Prevention wi initiay report into the Menta Heath Division. 6
Socia Care Disabiity Services Nationa Office Integrated Services Directorate Socia Care Division Pat Heay Oder Persons Services Integrated Services Directorate Socia Care Division Pat Heay Nationa Office Nursing Home Support Scheme Integrated Services Directorate Socia Care Division Pat Heay Pubic Heath and Heath Promotion Heath Protection Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe HSE Heath Protection Surveiance Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe Nationa Immunisation Office Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe Heath Promotion Corporate Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe Heath Promotion (Regiona) Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe (RDOs) Heath Inteigence Quaity and Patient Safety Heath and Webeing Division Stephanie O Keeffe Pubic Heath and Pubic Heath Quaity and Patient Safety Heath and Webeing Division Stephanie O Keeffe Departments Environmenta Heath and Emergency Panning Environmenta Heath Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe Emergency Panning Integrated Services Directorate Heath and Webeing Division Stephanie O Keeffe ISD Quaity and Patient Safety ISD Quaity and Patient Safety Integrated Services Directorate Quaity and Patient Safety Phiip Crowey Division Service Arrangements Service Arrangements Nationa Integrated Services Directorate Socia Care Division Pat Heay Business Unit Researched and written by Karen Griffin for IMPACT trade union. September 2013. 7
You re safer in IMPACT IMPACT membership deivers... Protection of your job, income and working conditions Professiona representation on workpace issues Financia services from saary protection to ife and trave insurance. IMPACT members are entited to... 4,000 specified critica iness or death benefit Free ega hep in bodiy injury cases 1850-77-66-44 Free 24/7 ega advice hepine 1850-77-66-44 Free 24/7 confidentia counseing hepine 1850-77-66-55 Free 24/7 domestic assistance hepine 1850-77-66-44 Terms and conditions appy. See www.impact.ie for detais. IMPACT Trade Union Phone: 01-817-1500 Emai: info@impact.ie www.impact.ie